Background : The introduction of upper gastrointestinal endoscopic examination to gastric mass screening may raise a risk of endoscopic complications. Methods : In order to study the incidence of complications associated with screening endoscopic examination, we analyzed a total of 61, 547 persons having undergone endoscopic checkup for gastric cancer detection from January 1998 to December 2002 in the Cancer Detection Center of Miyagi Cancer Society. Results : Severe complications requiring hospitalization occurred in 8 cases (0.012%) ; 6 sever hemorrhages (0.009%) and 2 perforations (0.003%). In addition, there were 149 cases with mild complications (0.242%), including 138 of mild bleeding (0.224%), 5 of indisposition caused by premedication (0.008%) and other mild complications. Conclusions : These results indicate that the importance of establishing measures to prevent endoscopic complications including careful interview prior to the examination and network systems to take care of patients with any complications after screening endoscopic examination.

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A 60-year-old male complaining of difficulty in swallowing and loss of body weight was admitted to our hospital on September 19, 2002. Upper GI endoscopy showed a protruding tumor, 25mm in diameter, on the anterior wall of the middle esophagus. The surface structure of the tumor was clarified as a gyrus-like pattern with indigo staining. The tumor and its peripheral mucosa were not dyed by iodine staining. The diagnosis of the tumor by biopsy was squamous cell carcinoma. Surgical resection of the thoracic esophagus and cardia of the stomach was performed on October 30. Histologically, a widespread non-staining area with iodine revealed squamous cell carcinoma and the protruding tumor was a basaloid cell car-cinoma. Most part of the tumor invasion was limited within the submucosal layer, but a tiny portion invaded the muscularis propria. In general, the shape of this type of tumor was a slightly elevated mass resembling a submucosal tumor because this tumor tended to grow laterally in the submucosal layer. In our case, however, the tumor sharply grew upward and became a polypoid mass consequently.

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A 73-year-old man with concomitant chronic heart and renal failure presented because of dysphagia. Endoscopic examination showed a giant protruding tumor located on the middle of the esophagus. Pathological findings on HE staining revealed poorly differentiated squamous cell carcinoma, so we performed radiotherapy and Nd : YAG laser, but the tumor was not reduced. Then we decided to use argon plasma coagulation (APC) 4 times a month. After APC treatment, an endoscope easily went through, and this patient achieved palliative clearance of the obstruction without any complications. Immunohistologically, tumor cells were positive for c-kit, CD34, vimentin and desmin, and negative for α-smooth muscle actin, S-100 and NSE, therefore the final histological diagnosis was malignant gastrointestinal stromal tumor (GIST), smooth muscle type. There have been no signs to suggest the passage disorder of esophagus. For the quality of life of the patient with inoperable tumor obstructing the esophagus, APC seems to be valuable and a palliative approach.

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A 74-year-old man was hospitalized because of massive hematemesis. He was previously diagnosed with Behcet's disease. Emergency gastrointestinal endoscopy revealed a Dieulafoy-like lesion above the esophago-gastric mucosal junction. A diagnosis of acute hemorrhagic Dieulafoy-like lesion was made. We successfully treated the Dieulafoy-like lesion usuing a ligating device of endoscopic variceal ligation (EVL). Permanent hemostasis was obtained with only one procedure. We herein present the first case of Dieulafoy-like lesion of the lower Esophagus associated with Behcet disease, and EVL succeeded in hemostasis for the lesion.

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A 55-year-old man had an early gastric cancer of 0-I+IIa type on the greater curvature of the lower body of the stomach. Marking by scalpel of needle type with high frequency current before the endoscopic mucosal resection was made slightly bigger (about a diameter of 30mm) than this lesion. By conventional Endoscopic Mucosal Resection using a Ligation device (EMRL) the 0-Ilesion would be divided in the center, and the depth of the lesion may not be correctly diagnosed. Therefore, we used clipping together with Endoscopic Mucosal Resection using a cap-fitted panendoscope (EMRC) employing a large device of soft and oblique and removed most of lesions including the 0-I portion endoscopically. Clipping together with EMRC was a new procedure having two advantages. This proce-dure lets the accuracy of mucosal resection increase first with its usefulness for the mucosal reconstruction, and secondly its hardness to slip a snare.

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A 41-year-old man was admitted to our hospital because of face and leg edema. Blood examination revealed hypoalbuminemia and positive reaction for anti-nuclear antibodies and anti-Sm antibodies. Abdominal scintigram using 99mTc-labeled human albumin revealed abnormal radioactivity in the ascending and transverse colon, suggesting albumin losing from terminal ileum or ascending colon. Colonoscopy revealed slight reddish mucosa and histology of biopsy specimen showed mild edema and inflammatory cell infiltration. Immunofluorescense study revealed deposition of C3 in the endothelium of colonic mucosa. Diagnosis of autoimmune protein-losing enteropathy was made. Steroid therapy was not effective and cyclophosphamide pulse therapy resulted in a significant recovery of serum albumin level and improvement of clinical symptoms.

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A 60-year-old man with a history of chronic alcoholic abuse was admitted to our hospital because of massive ascites. MRI demonstrated a cystic lesion at the pancreas body and contiguous leakage of the fluid along the hepato-duodenal ligament. ERP was performed. After confirming leakage of contrast material from the pancreatic pseudocyst, a 5Fr naso-pancreatic drainage catheter was placed to bridge the cyst. Massive ascites disappeared in two months subsequent to the drainage. A 5Fr, 7 cm-long plastic stent was placed to bridge the cyst for additional one month. There has been no sign of recurrence of pancreatic pseudocyst and leakage after stent removal. Endoscopic pancreatic stenting is considered to be an effective treatment for pancreatic ascites.

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A 57-year-old man having undergone total gastrectomy for gastric cancer was admitted to the hospital because of difficulty in swallowing. Endoscopic examination revealed a severe stenosis in the jejunum 5cm distal to the esophago-jejunal anastomosis. With abdominal CT and rectal examination, we made a diagnosis of malignant stenosis due to peritoneal dissemina-tion. We decided to place a covered self-expandable metallic stent. However, the delivery system could not pass through the bend because the jejunum was bent. Then a silk gut tied up to the delivery system was grasped with forceps endoscopically, and the delivery system was led successfully. After placement of the stent, the patient could leave the hospital and take food for 4 months. Against re-stenosis, a stent-in-stent technique was also made. The stent placement for jejunal stenosis is relatively difficult. This technique could apply to these cases, and would improve a quality of life for these patients.

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In recent years, clipping technique, mainly placation of the wound, is frequently used to prevent hemorrhage after colonoscopic polypectomy. However, this procedure requires a number of clippings for a single lesion, and the application criteria tend to be focused on the size of lesions alone. In contrast, after sufficiently observing the wound conditions, particularly possible hemorrhage, by injecting water after polypectomy, we directly performed clipping on the oozing site and the exposed blood vessels with minimal clippings needed. High preventive effect against bleeding as well as reduction of treatment time was noted. Clipping-related complications were prevented as well. This is a simple and useful procedure based on the wound condition after polypectomy.

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Background : A retrospective endoscopic follow-up study was conducted to elucidate the development of minute or superficial-type cancers. Methods : The development of eight colorectal cancers that were followed up by endoscopy was evaluated. Results : (i) Cancer with high-grade atypia frequently developed from lesions diagnosed histologically by biopsy as adenoma ; (ii) two polypoid adenomas developed into invasive cancers with non-polypoid configuration ; (iii) a superficial elevated-type cancer with high-grade atypia remained a mucosal cancer for more than 1 year ; (iv) a superficial depressed (SD) -type cancer that had a concomitant adenomatous component grew slowly, maintaining the same configuration for more than 2 years. Another SD-type cancer grew rapidly to an advanced cancer ; and (v) a superficial elevated adenoma developed into a ha + IIc-type submucosally invasive cancer while maintaining the size of the initial tumor. From the analysis of the literature, 35 lesions were collected, but it was impossible to speculate which specific type of tumor grew rapidly. Conclusions : From the endoscopic observations of the present study and the review of the literature, developments of superficial type cancers were diverse, sessile-type cancers with marked configurational change, and early cancers developed slowly, although the speed of their growth accelerated according to the downward invasion of the cancer.

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Background : Intraductal papillary-mucinous tumor (IPMT) of the pancreas has a broad spectrum of histology ranging from hyperplasia to adenocarcinoma. Therefore, it is important to differentiate between the malignant and benign lesions to determine the therapeutic strategy for IPMT. Patients and Methods : Thirty-nine patients with IPMT (27 men and 12 women, mean age : 63.3 years) underwent surgery between January 1985 and March 2002. The size of the cystic lesion, the maximum diameter of the main pancreatic duct (MPD), and the height of the papillary tumor inside the cyst were investigated by endoscopic ultrasonography (EUS) and/or intraductal ultrasonography (IDUS) before operation. These preoperative clinical findings were compared with the pathological findings of the resected specimen. Results : The size of the cystic lesion, the diameter of MPD, and the height of the papillary tumor in cases with malignant IPMT (invasive and non-invasive carcinoma) were larger than those in cases with benign IPMT (adenoma and hyperplasia). Analysis of the images of the lesions revealed that the following three factors are important for diagnosing IPMT : (i) the size of the cystic lesion is > 30mm ; (ii) the diameter of MPD is > 8mm ; (iii) the height of the papillary tumor inside the cyst is >3mm. It was not significant to differentiate between benign and malignant IPMT based on factor (i), but statistically significant (p <0.001) based on factors (ii) and (iii). Conclusions : EUS and IDUS are useful in the differential diagnosis of IPMT, especially in the differentiation between malignant and benign IPMT.

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